The decision making can be defined as the mental process in which a “choice is made after reflecting on the consequences of that choice” (Bechara & Van Der Linden, 2005; Bechara et al., 1997). It is a complex process that involves cognitive as well as emotion-based functions. In fact human beings make fast adaptive decisions in daily life, and that is based on the skill to relate emotion to contextual stimuli in order to anticipate outcomes through activation of emotional states (Bechara et al., 2005). In this regard, the ventromedial prefrontal cortex (VMPFC) has been widely recognized to play a key role in the emotional decision making process. The VMPFC includes the medial part of the orbitofrontal cortex (OFC), the more ventral sectors of the medial prefrontal cortex and the anterior cingulate cortex (Bechara et al., 1997). In particular the OFC, within the VMPFC, is part of a neural system underpinning decision-making and reward-related behaviours which are thought to be linked to social conduct (Rolls, 2000).

Aims - The paper reviews recent findings from the WHO World Mental Health (WMH) surveys on the global burden of mental disorders. Methods - The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders. Results - The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1–36.1%. The IQR of 12-month prevalence estimates is 9.8–19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4–6.8% in half the countries, 2.3–3.6% in one-fourth, and 0.8–1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions in the WMH data. Adult mental disorders are found to be associated with such high role impairment in the WMH data that available clinical interventions could have positive cost-effectiveness ratios. Conclusions - Mental disorders are commonly occurring and often seriously impairing in many countries throughout the world. Expansion of treatment could be cost-effective from both employer and societal perspectives

Language disturbances represent a core feature of schizophrenia, affecting social interactions and quality of life. Here we summarize linguistic and pragmatic deficits and illustrate the role of brain imaging studies in delineating the neural substrates of language deficits in patients with schizophrenia.

Background – People suffering from schizophrenia have markedly increased physical morbidity and mortality. A poor diet and sedentary lifestyle make a significant contribution to this ill health. Healthcare professionals need to include assessments of diet and to promote a ‘healthy living’ lifestyle. Aims – To describe the dietary habits and cardiovascular risk factors of people with chronic schizophrenia living in supported accommodation and to audit the provision of cardiovascular health screening in this population. Method – The dietary habits of 69 people with chronic schizophrenia living in community settings were assessed. Tobacco smoking, body mass indices and waist circumference were also measured. The dietary behaviour of patients living in high care settings with care staff present every day was compared with those in low care settings. Results – Residents in both levels of care made poor dietary choices. Patients in high care were consuming more fast food than those in low care. The dietary habits of men and women in both levels of care were worse than reported by surveys of the general population in England. All patients had seen their GP in the previous year though only 3 had received diabetes screening and fewer than half had lipid profiles. Conclusions – People with schizophrenia do not improve their diet just by the provision of healthy food as was the case in high care settings. Secondary care services must address physical health monitoring as well as mental health if the increased mortality of patients with schizophrenia is to be addressed effectively. More effective interventions are necessary to improve and sustain a healthy diet.

Declaration of Interest: Nothing to declare.

Background – As a large number of persons are exposed to prescribed psychotropic drugs, their utilisation and impact should be further explored at the population level. Aims – To illustrate the interest of pharmacoepidemiological studies of psychotropic drugs by selected examples of major public health issues. Method – Selective review of the literature. Results – Many questions remain unsolved regarding the behavioural teratogenicity of prenatal exposure to psychotropic drugs, the impact of their increasing use in children, the long-term cognitive consequences of exposure to benzodiazepines, and the risks associated with extension of indications of antipsychotic drugs. Conclusion – Pharmacoepidemiological studies need to be further developed owing to the large number of public health questions raised by the extensive and expanding use of psychotropic drugs.

Aims – To evaluate new generation antidepressants in relation to the placebo response. Methods – I review meta-analyses in which response to antidepressant medication and response to placebo were calculated. Results – All but one of these meta-analyses included unpublished as well as published trials. Most trials failed to show a significant advantage of SSRIs over inert placebo, and the differences between drug and placebo are not clinically significant for most depressed patients. Documents obtained from the U.S. Food and Drug Administration (FDA) revealed an explicit decision to keep this information from the public and from prescribing physicians. Conclusions – Because they do not incur drug risks, exercise and psychotherapy, which show at benefits at least equal to those of antidepressants, may be a better treatment choice for depressed individuals.

Declaration of Interest: The author has not in the last 2 years received any support, including that from drug companies and honoraria for lectures and consultancies, from interests potentially in conflict with this work.

Inserting adults with psychic problems into families has recently been practiced in various European countries and also in Italy, where some mental health departments support such families. Beyond the well known story of Gheel, the etero and omofamily care of psychiatric patients has a forgotten history. Methods – On the basis of unexplored and exceptionally rich sources from the archives of the asylums in Florence, as well as of the Province di Florence, which funded assistance to the mentally ill – this research focuses on the subsidized “domestic custody” of hundreds of psychiatric patients, who had already been institutionalized. Beginning in 1866, outboarding was supported by the provincial administration in Florence with the collaboration of the asylum medical direction. Results – In the late 19th C. and in the early 20th C. prestigious psychiatrists sought alternatives to the institutionalisation. These alternatives involved varied participants in a community (the patients and their families, the administrators and the medical specialists, the neighborhood and the police). The families played a special role that historians of the psychiatry exclusively dedicated to the insane asylums have not really seen. Conclusions – The role of the families in the interaction with the psychiatric staff is not, even on a historiographical level, simply an additional and marginal chapter of the practices and of the culture of the mental health. These archival evidence contradicts some common places on the past of the Italian psychiatry before 1978, and provokes new reflections of possible relevance to the present.

Aims – To describe the employment status of people using mental health service in Pavia, Italy; to explore their employment aspirations and perceptions of support to achieve these; and to test the feasibility of working with service users as researchers. Method – Face to face interviews carried out by two service user researchers with a consecutive sample of 200 service users attending the local psychiatric outpatient department using a translated version of a questionnaire developed for previous UK surveys. Results – A higher proportion of survey participants (42.5%) were in paid work compared to the UK, but 62.4% of those in work were dissatisfied with their employment. Amongst unemployed participants, 65.2% were interested in gaining employment but only 29.3% were receiving support to do so. Support was mainly limited to referral on to a generic disability organisation. The service user researchers carried out the survey to a high standard and reported benefits from undertaking the work. Conclusions – The results indicate a need in Pavia for specialist employment support using the Individual Placement and Support approach. Further development of service user involvement in research is indicated.

Aims – To assess using two well-know scales (DAI-30 and SWN) the drug attitude and subjective well-being of patients treated with haloperidol or second-generation antipsychotics (SGA) in four different Italian communities. Methods – The sample included 145 patients taking five different antipsychotics (APs) in mono-therapy: haloperidol, clozapine, olanzapine, risperidone, quetiapine. A stepwise multiple regression analysis (SMRA) was used to analyse the contribution of different AP treatments and of other predictors to SWN and DAI-30 scores. Results – Univariate analyses showed no differences in DAI-30 and SWN scores across treatments. The SMRA showed that SWN scores were negatively correlated with the severity of the psychoses (BPRS scores), while the DAI-30 scores were negatively correlated with the severity of the psychoses and positively correlated both with the length of drug treatment and with the use of olanzapine. Conclusions – Our study does not confirm a better drug attitude in patients treated with SGA with respect to haloperidol. The only partial exception is the better performance of olanzapine over haloperidol on DAI-30, which could be due to the lower use of anticholinergic drugs during olanzapine treatment. The differences between the SWN and DAI-30 may give good reason for the use of both instruments during AP treatments.

Declaration of Interest: No grants have been received for this study. In the last two years: Matteo Balestrieri has received grants from AstraZeneca, Eli Lilly, BMS, Janssen-Cilag, Boehringer-Ingelheim, Innova-Pharma, Pfizer, Bristol, Abbott, Lundbeck; Guido Di Sciascio has received grants from AstraZeneca, Eli Lilly, BMS, Janssen-Cilag, Sanofi-Aventis, Wyeth, Boehringer- Ingelheim; Elisa Maso has received grants from Pfizer; Cesario Bellantuono has received grants from Eli Lilly, BMS, Boehringer- Ingelheim, Innova-Pharma, Italfarmaco; The other authors have not received any grants in the last two years.

Aim – The high economic and social costs associated with the ‘common mental disorders’, and the need to scale up appropriate care services, are now widely recognized, but responses vary from country to country. In Britain, a current government initiative to promote psychological therapy is driven both by economic pressures and by research on the factors of happiness, or life-satisfaction. This article provides a short critical review of the project. Method – A health policy analysis, with regard to problem definition; objectives; sources of information; criteria for evaluation; impact on existing services, and comparison with alternative strategies. Results – The new programme, Improving Access to Psychological Therapies (IAPT), aims to expand treatment services by training 3,600 ‘psychological therapists’ in cognitive behavioural therapy (CBT), which they will then apply in the wider community. This service, with an initial budget of £173 million, will provide treatment for depression and chronic anxiety from local centres across the country. The programme is intended to pay for itself by reducing incapacity costs. Closer examination, however, raises questions concerning the project’s theoretical basis, logistics and research methodology, and casts doubt on its advantages over alternative approaches. Conclusions – The IAPT project is ill-designed to achieve its objectives and unsuitable as a model for treatment and care of the common mental disorders in other countries. An alternative strategy, based on closer integration of community mental health and primary health care, should be tested and on previous experience seems likely to prove more cost-effective.

Declaration of Interest: None.

Aims – ‘difficult patients’ may evoke strong feelings in health professionals. The ambivalent attitude of, especially, non-psychotic chronic patients towards psychiatric care may be frustrating and burdensome to professionals. Many of these patients are cared for in non-specialized services, where professionals are often more used to working with psychotic patients. Specific problems with ‘difficult’ non-psychotic patients may occur, and hamper the quality of care offered. The aim of this research is to determine precisely what problems psychiatric professionals perceive in contact with non-psychotic chronic patients in order to identify starting points for alternative or improved care in non-specialized services. Methods – a modified five-phase Delphi study with three groups of eight participants from was used to identify and prioritize experts' judgments. Results – 46 problems were identified of which some were relevant to one or two subgroups and some were relevant to the entire group. Conclusions – a program that combines a coherent view at services level, with support and increased communication at the interprofessional level (e.g. through regular supervision, sharing of case-loads) may be highly beneficial to non-specialized services.

Declaration of Interest: None for any author. Funding for this study was provided by ZonMW ‘Geestkracht’ (Grant 100–002–031), Altrecht Mental Health Care and Gelderse Roos Mental Health Care.

Aims – Postnatal depression, the most frequent complication occurring after pregnancy, is often not recognized. The prevalence of postnatal depression is currently considered to be 10–15% in western countries. A wide range of risk factors related to postnatal depression were researched in international studies. Our aim was to evaluate the risk factors and their frequency in a women population of Bergamo Province and compare the results with findings of international literature. Methods – 595 women taking part to antenatal courses in three hospitals in Bergamo Province were screened for Postnatal Depression using EPDS and clinical interview. Prevalence and possible psychosocial risk factors data were collected and subsequently analysed and compared with literature findings. Results – Thirty six (7.1%) women of our sample had postnatal depression. Depressed mood and depression during pregnancy, anxiety during pregnancy, poor social support, recent life events, a history of depression or other psychiatric history, presence of maternity blues were the strongest predictors of postnatal depression in our sample. Conclusions – The Psychosocial risk factors emerged from our study are substantially the same indicated by international studies, on the contrary prevalence is a little lower. This result may be explained considering that our women sample wasn't completely representative of general population.

Declaration of Interest: Results of this study are part of a project, “Identification and early treatment of post partum depression”, approved and financially supported by Regione Lombardia. This study didn't receive grants or support from drug companies. There are no conflicts of interest.

Aim – The association between sporting activities, or lack there of, and suicidal behaviour has not yet been clarified. The objective of this study was to determine, if sports participation has an impact on risk for completed suicide. Methods – Axis I and Axis II disorders, sociodemographic factors, and current and former sports activities, including various sports disciplines, were assessed by a semi-structured interview by psychological autopsy method in 163 suicides and by personal interview in 396 living population-based control persons. Results – Current sports activities (OR = 0.24, 95%CI, 0.15 to 0.39; OR = 0.27, 95%CI, 0.16 to 0.45) and sports activities at some point in life (OR = 0.33, 95%CI, 0.18 to 0.62; OR = 0.40, 95%CI, 0.23 to 0.68, after adjustment for axis I and II disorders or educational level, each) were associated with decreased suicide risk. Conclusions – Current sports activities and sports activities at some point in life may reduce suicide risk.

Declaration of Interest: Barbara Schneider got research funding as young scientist for the project “Psychopathological, sociodemographic, psychosocial, and work-related risk factors for suicide” from the faculty representative committee of the Faculty of Medicine, Johann Wolfgang Goethe-University of Frankfurt/Main. Furthermore, “Nachlaβ Martha Schmelz”, part of the university foundation of Frankfurt am Main, supported the research project. There was no support from drug companies related to the present paper. Barbara Schneider, Klaus Georgi, and Axel Schnabel are employed at the Goethe-University Hospital and Faculty of Medicine. Bettina Müller is employed at the Markus Hospital, Frankfurt /Main.

Aims – The study aims to evaluate the frequency of association between Axis I and II disorders according to DSMIVTR criteria and obesity, and use of mental health services in a clinical sample of patients attending a centre for the diagnosis and treatment of Obesity. Methods – 150 consecutive patients (32 Males, 118 females, mean age 44.614.3 yrs; mean BMI 35.46.2) were interviewed by means of SCID I and SCID II. Results – Lifetime Prevalence of Axis I disorders was 58% (males 50%; females 61%); the highest prevalence rate was found for Anxiety Disorders (approx 35%), whilst 30% of subjects were affected by Mood disorders, chiefly Major Depression (20%), and 18% by Eating Disorders. 28% of obese patients presented a Personality Disorder, 23% of patients being affected both by an Axis I and Axis II disorder. Mood Disorders, in particular Major Depression, were significantly prevalent among female obese. 50% of females and approx 37% males included in the sample had contacted mental health units for treatment. Conclusion – Data obtained in the present study confirm the high prevalence rates of mental disorders in obese patients seeking treatment. Specialist units should therefore include thorough psychiatric evaluation of patients as a routine practice.

Declaration of Interest: The study was supported by a research grant by University of Cagliari (ex 60% funding, financial year 2006); the authors declare no conflict of interest.

Aims – To describe what users with schizophrenia think about the causes of their disorder. Methods – In each of the 10 participating Italian mental health centres, 25 users with schizophrenia were consecutively recruited and asked to complete the Users' Opinions Questionnaire (UOQ). Results – 150 out of 198 respondents mentioned at least one social cause for their mental disorder, and 114 reported exclusively social causes. Family conflicts were the most frequently reported social cause (21%), followed by traumas (20%), work and study difficulties (17%), and psychological disturbances (17%). Ten percent of the respondents mentioned biological causes. Biological causes were more frequently reported by users who were aware of their diagnosis of schizophrenia, whereas social causes by those who just knew they suffered from a psychosis. Difficulties in social relationships were more frequently pointed out by respondents with an earlier onset of the illness and a higher number of compulsory admissions in the previous 12 months. These users expressed more scepticism about the usefulness of the treatments they received, and perceived a greater social distance. Conclusions – Users' beliefs about the causes of their disorder should be taken into account by psychiatrists in order to improve their working alliance with them.

Declaration of Interest: None of the authors has had any interest or he/she has received any form of support, including that from drug companies and honoraria for lectures and consultancies, potentially in conflict with this scientific work. None of the authors has received any form of fee for his/her participation in this study. This study was supported by a grant received from the “M. Lugli” Foundation (grant no. 2–18–8).

Aim – Since the importance of latitude of living for the prevalence of Seasonal Affective Disorder (SAD) is unclear, the study aims to test the latitude hypothesis by comparing SAD in two rather similar groups of students living at latitudes far apart. Methods – Two groups of students, 199 in Tromsø, Norway (690 N) and 188 in Ferrara, Italy (440 N) were asked to fill in the Seasonal Pattern Assessment Questionnaire. Results – Global Seasonality score (GS-score) was significantly higher in Italian than in Norwegian students, in females and in students with sleeping-problems. Norwegian students had significantly higher SAD prevalence in winter and in spring. Most people in both countries felt worst in October and November, and the prevalence of Autumn SAD was not significantly different between the two countries. Conclusions – The hypothesis that SAD is linked to amount of environmental light and latitude of living was not supported.

Declaration of Interest: The study was fully financed by the University of Tromsø and the University Hospital North Norway, and there are no conflicts of interests.

Aim – To test the hypothesis that stressful life events, in particular intrusive events, would cluster before the first onset of psychosis. Method – Forty-one patients with first episode psychosis were interviewed with the Life Events and Difficulties Schedule to assess events in the year before the onset of illness. Events were rated contextually on timing, independence, threat, and intrusiveness. Within-patient group clustering was evaluated, and the patient group was compared with two general population surveys from London. Results – Events were very frequent in the year before the onset of psychosis. Stressful and intrusive events were more common in the three months before onset compared with the previous nine months, although few analyses reached conventional statistical significance. Threatening and intrusive events were much more frequent in patients than in the comparison groups. First episode psychosis patients were strikingly more likely to report an intrusive event in the three months before onset (OR=17.1, 34% v 3%), and also showed an excess between three months and one year before onset (OR=8.1, 11% v 3%). Conclusions – Events may trigger many cases of first episode psychosis. The effect emerges several months before onset, particularly if the events are intrusive. This has both theoretical and clinical implications.

Declaration of Interest: DR was supported by a UK Medical Research Council studentship. The authors have no conflicts of interest in writing this paper.

Aims – The use of specialised services to avoid admission to hospital for people experiencing mental health crises is seen as an integral part of psychiatric services in some countries. The aim of this paper is to assess the impact on costs and costeffectiveness of a crisis resolution team (CRT). Methods – Patients who were experiencing mental health crises sufficient for admission to be considered were randomised to either care provided by a CRT or standard services. The primary outcome measure was inpatient days over a six-month follow-up period. Service use was measured, costs calculated and cost-effectiveness assessed. Results – Patients receiving care from the CRT had non-inpatient costs £768 higher than patients receiving standard care (90% CI, £153 to £1375). With the inclusion of inpatient costs the costs for the CRT group were £2438 lower for the CRT group (90% CI, £937 to £3922). If one less day spent as an inpatient was valued at £100, there would be a 99.5% likelihood of the CRT being costeffective. Conclusion – This CRT was shown to be cost-effective for modest values placed on reductions in inpatient stays.

Aims – Nidotherapy is the systematic modification of the environment to create a better fit for people. This is the first randomized controlled trial of its efficacy in an assertive community team. Methods – Patients in an assertive outreach team with continued management problems together with comorbid personality disturbance and severe mental illness were randomized to nidotherapy enhanced assertive treatment (up to 12 sessions) or to continued assertive outreach care. Use of psychiatric beds over one years (primary outcome) and change from base-line in other health service resources, psychiatric symptoms, social functioning and engagement with services were measured at 6 and 12 months (secondary outcomes). Results – 52 patients were recruited over 13 months, with 49 and 37 assessed at 6 and 12 months. Patients referred to nidotherapy had a 63% reduction in hospital bed use after one year compared with control assertive care (P=0.13) and showed non-significant improvement in psychiatric symptoms, social functioning and engagement than the control group. The mean cost savings for each patient allocated to nidotherapy was £4,112 per year, mainly as a consequence of reduced psychiatric bed use. Conclusion – Nidotherapy may be a cost-effective option in the management of comorbid serious mental illness and personality disorder, but larger confirmatory trials are necessary.